Provider Demographics
NPI:1538461363
Name:SPEED OF LIGHT XRAY, LLC
Entity Type:Organization
Organization Name:SPEED OF LIGHT XRAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:MAGNESS
Authorized Official - Suffix:
Authorized Official - Credentials:RT(R)
Authorized Official - Phone:903-363-9583
Mailing Address - Street 1:3200 TROUP HWY STE 130
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8330
Mailing Address - Country:US
Mailing Address - Phone:903-363-9583
Mailing Address - Fax:903-363-9583
Practice Address - Street 1:3200 TROUP HWY STE 130
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8330
Practice Address - Country:US
Practice Address - Phone:903-316-6611
Practice Address - Fax:903-363-9583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218271901Medicaid
TX459919OtherMEDICARE PTAN